HomeMy WebLinkAboutMiscellaneous - 186 INGALLS STREET 11/30/2015 (2) i
1
Commonwealth of Massachusetts Map-Block-Lot 1
10630047
BOARD OF HEALTH Permit No J
North Andover BHP-2015-0380
FEE
$250.00
DISPOSAL WORKS CONSTRUCTION I`t
Permission is hereby granted Todd Bateson
to(Construct)an Individual Sewage Disposal System.
at No 186 INGALLS STREET
as shown on the application for Disposal Works Construction Permit No. 13HP-20157038 Dated September 14,2015
------- - r_( 1
Issued On: Sep-14-2015 ,tOARD O
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O a 4 F,mF
z lit r Septic, 1 f �/ ToDArs DATE �I
Construction,Perm it TOWN OF
250':00'—Full Repair
NORTH ANDOVER, 01845 $' 25.00-Component
Important: Application is hereby made for a pennitto:
When filling out ❑Construct a new on-site sewage disposal system*
forms on the
computer,use m6pair or replace an existing.on-site sewage disposal'system*
only the tab key ®Repair or replace an existing system component—What?
to move your
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
t�s
Cityfrown ", Az 4.
2.- TYPE OF SEPTIC SYSTEM*:
9 ❑Pump ravity(choose one)
"f pump system,attach copy of electrical permit to application*"
➢ ❑Conventional System(pipe and stone system)
➢ ❑Infiltrator or Blodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
➢ ❑Pressure Distribution S.A-S.(No D-Box)
➢ ❑Pressure Dosed(D-Box Present)S:A.S.
➢ ❑ Does the system require an effluent fitter? Yes No
If yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of filter before DWG issuance)
Whatis the Make? What is the Modet''
2. Owner Information
Name
Address(if different from abov )
State Z d p Code
e
Telephone Number
3. Installer Information
Name Name of Company
Address 111 ARGIILLA F'1,0AD
ANDOVER, MA 01 810
Cityfrown State Zip Code
Telephone Number(Cell Phone#If possible please)
4. Designer jnforgraflon _
Name Name of Company
Address
LA:T (, G
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
i
,,..,,•+ti Applicati-e h for Septic Disposal System
a . TODAY'S DATE
Construction -Perm it = TOE OF
® O�4'.:7 $.250.0®,Full Repair
eaug $125.00.•Component
PAGE 2
A. a.6111ty.lnformation continued....
S. T e'of Buildin : esi eentiai Dwellin or❑Commercial
g
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-sJte sewage dispose!system In accordance with the prov/slons of Titles of the
Environmental Code, as well as the Local Subsurface Disposal Regulatlons for the Town of
North Andover, and not to place the system In operation unfll a Certificate of Compliance has
been Issued by s Board of Health.
7°'
Name
Date
i
:ri ., ._.....
Ap atipn pproved y r of e.lth Re P resentative)
w
Na e
Date
Application Dlsapproved,for the following reasons:
For Office Use Only.
1. Fee Attached? Yes °"pp^
No
2.• PtolectAfardager Obligation Form Attached, Yes
3,: Penn Svs.__ter!+? Ifso)Attach cen afElectr%r�1 prrrnit` 'es No
4. FoundatibnAs Bur'It.?(new construction-ronly), Yes No
(Same scale as approycd plan)
S. FloorPlans?(hew construction'only): Yes
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